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4,__. <br /> - t <br /> p. �.` <br /> Ao. <br /> _ :.:.:, <br /> ,..„ ....,,... <br /> _..:.,-,,,,,,.;: <br /> , ..„,,.,„•.:‘,2„,•-•.••„._,-- <br /> =--� =-- CITE' ®f ORONO <br /> ,!-_-„,„:• -„-,-,,, <br /> s_.;-. , Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> Q <br /> daErau On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3 . The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5 . You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ( i 6 /c'/ - /I C )a4; ,e--- _ <br /> First -, Middle Last <br /> *?,9Q57— ‘/t, / !i : ,t.,-t.,-L____) 4;?' <br /> Address <br /> 01..:._?13t.7±!....:.._,., f , --- --3-' -- `- <br /> City State Zip <br /> 5/7_.5) 0 7,__-:j S - <br /> Phone <br /> I understand my rights as stated a.K•ve. <br /> / .2- ..ii' <br /> • <br /> Signature • <br /> BUILDING& ZONING—473-7357 • ADMINISTRATION Sc FINANCE — 473-7353 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />